- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.43 / $160.43 / $797.19
| Professional | | $160.43 | $160.43 | $797.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.00 / $392.00 / $1,829.00
| Professional | | $314.00 | $392.00 | $1,829.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.82 / $384.93 / $1,580.83
| Professional | | $240.82 | $384.93 | $1,580.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.09 / $1,992.82 / $3,078.25
| Professional | | $1,189.09 | $1,992.82 | $3,078.25 |